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    Obstetrics Case Study

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    bh2212
    BR is a 34-year-old pregnant woman admitted for a scheduled c-section, her first child. She has gestational diabetes and a family history of diabetes. Her prenatal care and labs are normal. She will need pain management after surgery and education on breastfeeding her newborn. Nursing diagnoses include readiness for breastfeeding and managing acute post-surgical pain.

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    Obstetrics Case Study

    Uploaded by

    bh2212
    419 views13 pages
    BR is a 34-year-old pregnant woman admitted for a scheduled c-section, her first child. She has gestational diabetes and a family history of diabetes. Her prenatal care and labs are normal. She will need pain management after surgery and education on breastfeeding her newborn. Nursing diagnoses include readiness for breastfeeding and managing acute post-surgical pain.

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    OB Case Study

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    BR is a 34-year-old pregnant woman admitted for a scheduled c-section, her first child. She has gestational diabetes and a family history of diabetes. Her prenatal care and labs are normal. She will need pain management after surgery and education on breastfeeding her newborn. Nursing diagnoses include readiness for breastfeeding and managing acute post-surgical pain.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    419 views13 pages

    Obstetrics Case Study

    Uploaded by

    bh2212
    BR is a 34-year-old pregnant woman admitted for a scheduled c-section, her first child. She has gestational diabetes and a family history of diabetes. Her prenatal care and labs are normal. She will need pain management after surgery and education on breastfeeding her newborn. Nursing diagnoses include readiness for breastfeeding and managing acute post-surgical pain.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 13

    Obstetrics Case Study

    By: Blayre Helm

    Reason for Hospitalization

    BR is a 34 year old, Caucasian female


    Admitted for scheduled caesarian section on day of clinical
    37 weeks pregnant
    Suffers from gestational diabetes
    First time mother
    Gravida: 1, Para: 1 (after the delivery of her child)

    Enhanced desire to breastfeed

    Past Medical History

    Rubella: Immunization given 3/11/15


    Blood Type: B
    Rh Status: +
    HIV: Negative
    Strep: Negative
    Hepatitis: Negative
    Previous Surgeries: Myomectomy
    Previous Birth History: none

    Family Medical History

    Mother: Diabetes Mellitus Type II


    Brother: Deletion of distal chromosome 18

    Psychosocial History

    Family make-up: Nuclear family made up of her and her husband


    Employment: Not employed
    Education: High school diploma
    Insurance: Medicaid
    Tobacco, Drug, and Alcohol use: Never
    Home environment: Safe with no stated or noted potential hazards
    Activates: No stated activates that the patient or her husband enjoyed
    Psychosocial stressors

    Physiological Status

    Virginia Hendersons Need Theory


    Increase the patients independence so that progress after
    hospitalization is not delayed

    Nursing care designed to accommodate physiological needs

    Developmental Status

    Erik Eriksons Psychosocial Development


    8 stages of development

    Nursing care designed to accommodate developmental needs

    Growth and Nutritional Status

    Height %: the patient is 54, therefore has a height % of 46.6%


    Weight %: the patient is 210 lbs, therefore has a weight % of 83.7%
    Weight for height %: not applicable (not a newborn)
    BMI: 33.97
    Appearance: Obese but pregnant
    Nutritional status: Follows gestational diabetic diet
    Nurse counseling: Balance in proteins, fats, and carbs
    After patient gives birth it is important for the patient to maintain a healthy diet and
    exercise so the risk for Type II DM is reduced

    Focused Physical Assessment


    Vital Signs: BP: 137/84, Temp: 98.8, HR: 109, RR: 16, SpO2: 95%
    General Appearance: White female appears her stated age and in no acute distress
    Lymph nodes: No clavicular, parotid, occipital, submandibular, cervical, or sub-clavicular
    adenopathy
    Head and neck: No thyroid enlargement
    EENT: conjunctiva, eyelids, ears, nose, and lips WNL; dentition appears to be in adequate
    state
    Chest/Lungs: clear to auscultation, normal respiratory effort
    Heart: normal rate and rhythm
    Back and Extremities: normal to inspection, no edema or cyanosis on any extremity, range
    of
    motion WNL
    Neurological : extremely deep tendon reflection intact

    Labs

    Rubella: immunization given 3/11/15


    Rh factor: +
    Hepatitis screening: Negative
    RDW: 20.8 (high)
    Neutrophils: 75.9% (high)

    Medications

    Acetaminophen: 650 mg, q6h, for pain


    Calcium Carbonate: 500 mg, q6h PRN, for dyspepsia
    Magnesium Hydroxide: 30 mL, nightly PRN, for constipation
    Ondansetron: 4 mg, q6h PRN, for nausea
    Oxycodone: 10 mg, q4h PRN, for severe pain levels 7-10 on
    a scale of 0-10

    Nursing Implications

    Overall, this patient is a healthy female who will be in pain due to her
    Caesarian section. She is very anxious about becoming a new mother and
    wanting to entirely breastfeed, which is a new concept to her.
    Nursing Dx:
    Readiness for enhanced breastfeeding r/t maternal requests and infant nutritional
    needs e/b the infant having proper alignment and latch-on techniques.
    Acute pain r/t surgical injury e/b pain being stated as >5 on a scale of 0-10.
    Knowledge deficit r/t becoming a new mother and starting to breastfeed as e/b
    inability to correctly position her newborn during breastfeeding.

    References
    Ackley, B., & Ladwig, G. (2014).Nursing Diagnosis Handbook(10th ed.). Maryland Heights, Missouri: Elsevier.
    Bone, R. L. (2015). Big Babies: An Exploration of Gestational Diabetes.International Journal Of Childbirth Education,30(3),
    42-46.
    Diabetes diet - gestational: MedlinePlus Medical Encyclopedia. (2013, August 5). Retrieved September 19, 2015, from
    https://www.nlm.nih.gov/medlineplus/ency/article/007430.htm
    Drugs.com. (2015). Retrieved September 20, 2015, from http://www.drugs.com/breastfeeding/oxycodone.html
    Gestational diabetes | BabyCenter. (2012, September 1). Retrieved September 19, 2015, from
    http://www.babycenter.com/0_gestational-diabetes_2058.bc?page=2
    Ladewig, P., & London, M. (2014).Contemporary maternal-newborn nursing care(8th ed., p. 108). Boston: Pearson.
    Manyonda, I., Upton, G., Evans-Jones, J., Ali, M., & Shehata, H. (1998). Red cell distribution width (RDW) changes in
    pregnancy. Retrieved September 19, 2015, from
    http://www.researchgate.net/publication/13563672_Red_cell_distribution_width_(RDW)_changes_in_pregnancy
    Pagana, K., & Pagana, T. (2014). Manual of Diagnostic and Laboratory Tests (Fifth ed., p. 526). St. Louiis, Missouri: Elsevier.
    Theories in Nursing. (2013, June 22). Retrieved September 19, 2015, from
    http://www.istudentnurse.com/fundamentals/theories/
    U.S. Census Bureau. (2007-2008). Retrieved September 19, 2015 from
    https://www.census.gov/compendia/statab/2012/tables/12s0209.pdf
    Vallerand, A., & Sanoski, C. (2014).Davis's drug guide for nurses(Fourteenth ed.). Philadelphia, PA: F.A. Davis Company.
    Waller-Wise, R. (2013). Utilizing Henderson's Nursing Theory in Childbirth Education.International Journal Of Childbirth
    Education,28(2), 30-34.

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